Health History and Physical Assessment

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Health History and Physical Assessment

• Rachel S. Natividad, RN, MSN, NP

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Health History Physical Assessment

• Subjective database
• Obtained through interview
• ID strength, actual or potential health problems,
  support system, teaching needs, DC and referral
  needs

• Objective database
• Obtained by observation and physical assessment
  techniques
• Completes the clients health picture

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Complete Health History (Jarvis)

• Biographical data
• Reason for Seeking Care
• History of Present Illness
• Past Health
• Accidents and Injuries
• Hospitalizations and Operations
• Family History
• Review of Systems
• Functional Assessment ( Activities of Daily
  Living)
• Perception of Health

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Complete Health History-Cont. Biographical Data
(exercise)

• Name
• Age
• Birthplace
• Gender
• Marital status
• Occupation

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Complete Health History-Cont.

• Reason for seeking care What brought you here
  today? (symptom/s duration)
• History of Present Illness
• Arranges symptoms in chronological order from the
  time of onset to the present time.
• Includes an Analysis of the Symptom

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Complete Health History-Cont.HPI Analysis of
the Symptom

• P Provokes
• Q Quality
• R Region/Radiation
• S Severity
• T Time

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Complete Health History-Cont.Review of Systems

• A series of questions re pts current and past
  health including health promotion practices
• Inquires about signs and symptoms as well as
  diseases related to each body system

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Exercise

• Interview a client (your partner) and obtain the
  following
• Reason for seeking care
• History of present illness (including Analysis of
  the symptom/complaint PQRST)
• Review of Systems (Complete PQRST for any
  positive symptom)

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Complete Health History-Cont.Document your
Findings

• Documentation forms vary per agency
• Use of standardized nursing admission assessment
  forms
• Combines health history and physical assessment

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Physical Assessment
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Physical Assessment- Cont.Assessment Sequencing
Techniques

• Head to - Toe Assessment
• Body Systems Assessment

• Inspection
• Palpation
• Percussion
• Auscultation

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Assessment techniques - Cont.Inspection

• Ensure good lighting
• Perform at every encounter with your client

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Assessment techniques - Cont.Palpation

• Palpation Techniques
• Light- rigidity, tenderness, masses
• Deep enlarged organ, tenderness, masses
• Bimanual-position, size, tenderness

• Temperature, Texture, Moisture
• Organ size and location
• Rigidity or spasms
• Crepitation Vibration
• Position Size
• Lumps or masses
• Tenderness or
• pain

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Assessment techniques - Cont.Percussion

• assess underlying structures for location, size,
  density of underlying tissue.
• Direct sinus tenderness
• Indirect- lung percussion
• Blunt percussion-organ tenderness

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Assessment techniques - Cont. Auscultation

• Listening to sounds produced by the body
• Instrument stethoscope (to skin)
• Diaphragm high pitched sounds
• Heart
• Lungs
• Abdomen
• Bell low pitched sounds
• Blood vessels

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Assessment techniques - Cont.

• Environment Equipment

• Proceed as follows
• General survey
• Head to toe or systems approach
• Minimize exposure
• Assess unaffected areas external parts first

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Physical Assessment- Cont. General Survey

• Appearance
• Age, skin color, facial features
• Include any signs of distress- facial grimacing,
  breathing problems
• Body Structure - Stature, nutrition, posture,
  position, symmetry
• Mobility - Gait, ROM
• Behavior
• Facial expression, mood/affect, speech, dress,
  hygiene
• Cognition
• Level of Consciousness and Orientation (x4)

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Documentation

• General Survey
• Alert, and oriented X4 speech clear. Well
  nourished 40 year old male. Dressed
  appropriately, clean well groomed. In no
  apparent distress (NAD), mood and affect
  appropriate for situation, gait steady, and
  posture relaxed.